A client admitted to the psychiatric unit diagnosed with major depression wants to sleep during the day, refuses to take a bath, and refuses to eat. Which nursing intervention should the nurse implement first?

Assess the client's ability to communicate with the other staff members.

Arrange a meeting with the family to discuss the client's situation.

Administer the client's antidepressant medication as prescribed.

Establish a structured routine for the client to follow.

Answer and Explanation

The Correct Answer is D

Choice A reason: Assessing communication ability is important but secondary to establishing a structured routine to address the client's immediate needs.

Choice B reason: Arranging a meeting with the family can provide support but is not the first priority in managing the client's depressive symptoms.

Choice C reason: Administering antidepressant medication is essential but must be part of an overall structured plan.

Choice D reason: Establishing a structured routine helps provide stability, encourages participation in daily activities, and addresses the client's refusal to eat and bathe.

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Correct Answer is C

Explanation

Choice A reason: Evaluating a client's mobility progress involves assessment and clinical judgment, which are beyond the scope of practice for a UAP.

Choice B reason: Titrating oxygen requires clinical judgment and understanding of the client's condition, which should be performed by licensed nursing staff.

Choice C reason: Procuring platelet products from the blood bank is within the scope of practice for a UAP as it involves following protocols and retrieving items, not direct patient care.

Choice D reason: Determining the diameter and depth of a client's dermal ulcer involves assessment and clinical judgment, which should be performed by licensed nursing staff.

A. Review last partial thromboplastin time (PTT) results. B. Auscultate bowel sounds in all quadrants. C. Monitor stools for presence of blood. D. Prepare to administer warfarin. E. Assess characteristics of pain.

Correct Answer is ["A","B","C","E"]

Explanation

Choice A reason: Reviewing the last PTT results is important to ensure that the heparin therapy is within the therapeutic range and to assess for potential over-anticoagulation.

Choice B reason: Auscultating bowel sounds in all quadrants helps determine if there is any bowel obstruction or ileus, which can be associated with abdominal pain.

Choice C reason: Monitoring stools for the presence of blood is essential to identify gastrointestinal bleeding, which can present as tarry, black stools.

Choice D reason: Preparing to administer warfarin is not appropriate in the acute management of potential gastrointestinal bleeding and should be done based on the healthcare provider's instructions.

Choice E reason: Assessing the characteristics of pain is important to better understand the cause of abdominal pain and guide further management.

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A client admitted to the psychiatric unit diagnosed with major depression wants to sleep during the day, refuses to take a bath, and refuses to eat. Which nursing intervention should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse leading a care team on a medical surgical unit is assigning client care to a practical nurse (PN) and an unlicensed assistive personnel (UAP). Which activity should the nurse assign to the UAP?

Correct Answer is C

Explanation

A client with deep vein thrombosis (DVT) is receiving a continuous heparin IV infusion. The client now has tarry, black diarrhea and reports abdominal pain. Which actions should the nurse implement? Select all that apply.

Correct Answer is ["A","B","C","E"]

Explanation

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